Delta Dental Small Business Solutions

Pediatric

Adult

See a Delta Dental Premier or Any Other Provider

Delta Dental PPO plus Premier TM Family Plan High Option (1-50 enrollees)

See a Delta Dental PPO Provider

See Any Provider

Annual Deductible – Individual/Family

$25 / $75 50 150

$25 / $75 50 150

$75 / $225

Out-of-Pocket Limit^

$350/$700 75

N/A

N/A

Individual Annual Maximum

N/A

$1,000

$750

CheckUp Plus TM CheckUp Plus™ lets enrollees obtain dental services such as evaluations, X-rays, cleanings, fluoride, sealants, and space maintainers without those costs reducing their plan-year individual annual maximum (see contract for details) Wellness and Preventive Services Cleanings, fluoride treatments, sealants, space maintainers covered for pediatric Diagnostic Services Evaluations two times per calendar year, bitewing X-rays once per year, full mouth X-rays once every five years

N/A

Included

Included

100%

100%

90%

100%

100%

90%

Basic Restorative Services Emergency treatment to relieve pain, llings

80%*

80%*

70%*

Major Restorative Services Root canal and gum-disease treatment, extractions and oral surgery, crowns, complete and partial dentures, implants, xed bridges, repairs and adjustments

50%*

50%*

40%*

Medically Necessary Orthodontic Services Treatment to help correct severe handicapping malocclusions caused by craniofacial orthopedic deformities involving the teeth

50%*

N/A

N/A

Dependent Age Limitation

19 19

26 26

26

This plan also includes:

*Deductible applies ^Services provided by an out-of-network provider do not accumulate toward the out-of-pocket limit.

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